C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart H—Appeals Under the Medicare Part B Program

42 C.F.R. § 405.803

Appeals rights

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(a) A provider or supplier may appeal the initial determination to deny a provider or supplier's enrollment application, or if applicable, to revoke current billing privileges by following the procedures specified in part 498 of this chapter.

(b) The reconsideration of a determination to deny or revoke a provider or supplier's Medicare billing privileges is handled by a CMS Regional Office or a contractor hearing officer not involved in the initial determination.

(c) Providers and suppliers have the opportunity to submit evidence related to the enrollment action. Providers and suppliers must, at the time of their request, submit all evidence that they want to be considered.

(d) If supporting evidence is not submitted with the appeal request, the contractor contacts the provider or supplier to try to obtain the evidence.

(e) If the provider or supplier fails to submit the evidence before the contractor issues its decision, the provider or supplier is precluded from introducing new evidence at higher levels of the appeals process.

Notes of Decisions
Cited in 29 cases (2 in the last 5 years), 1980–2023 · leading case: Schweiker v. McClure, 456 U.S. 188 (1982).
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Schweiker v. McClure, 456 U.S. 188 (1982). · cites it 2× “IV); 42 CFR §405.803 (b) (1980). If it determines that the claim meets all these criteria, the carrier pays the claim out of the Government’s Trust Fund—not out of its own pocket.”
Gray Panthers v. Richard S. Schweiker, Sec'y of the Dep't of Health & Human Servs., 652 F.2d 146 (D.C. Cir. 1981). “See also 42 CFR § 405.803 (b). Waiver decisions are always made at the reconsideration level.”
Gulfcoast Med. Supply, Inc. v. Sec'y, Dep't of Health & Human Servs., 468 F.3d 1347 (11th Cir. 2006). “To facilitate claims processing, the Medicare Act permits DME suppliers to distribute to physicians a “certifícate of medical necessity” (CMN).”
MIDLAND PSYCHIATRIC Assocs., INC., Appellant, v. UNITED STATES of Am.; Mut. of Omaha Ins. Co., Appellees, 145 F.3d 1000 (8th Cir. 1998). “See 42 C.F.R. §§ 405.803 (a), (b) (1997). Here, for example, to decide the coverage question, Mutual had to determine whether Midland’s services were “reasonable and necessary for the diagnosis and active treatment of the individual’s condition.”
MacKenzie Med. Supply, Inc. v. Leavitt, 506 F.3d 341 (4th Cir. 2007). “42 C.F.R. §§ 405.803 , 421.200. Carriers also conducted audits of the claims submitted for payment, and adjusted payments and payment requests.”
Mobile Med. Servs., Inc. v. Arkansas Blue Cross & Blue Shield, 676 F. Supp. 194 (W.D. Ark. 1987). · cites it 3× “” See 42 C.F.R. § 405.803 (a). The initial determination includes “a determination as to whether items and services furnished are covered.”
United Sr Assn Inc v. Shalala, Donna, 182 F.3d 965 (D.C. Cir. 1999). “42 C.F.R. § 405.803 ; id. § 421.200. Medicare beneficiaries, or the physicians to whom they have assigned their rights to payment, may require carriers to review their determinations and are entitled to post-review hearings.”
David v. Heckler, 591 F. Supp. 1033 (E.D.N.Y 1984). “42 C.F.R. § 405.803 . The claimant may then request a review of the decision.”
In Re Nuclear Imaging Sys., Inc., 260 B.R. 724 (Bankr. E.D. Pa. 2000). “IV); 42 CFR § 405.803 (b) (1980). If it determines that the claim meets all these criteria, the carrier pays the claim out of the Government’s Trust Fund— not out of its own pocket.”
Almy v. Sebelius, 749 F. Supp. 2d 315 (D. Maryland 2010). “§ 1395u; 42 C.F.R. §§ 405.803 , 421.200. Claims by DME suppliers are submitted to jurisdiction-specific administrative contractors called DME Medicare Administrative Contractors (“DMACs”) for processing.”
Courtney v. Choplin, 195 F. Supp. 2d 649 (D.N.J. 2002). “See 42 C.F.R. §§ 405.803 , 405.804. A beneficiary or supplier dissatisfied with the carrier’s initial reimbursement determination-must, within six months of the date of the notice of the carrier’s adverse determination is received, make a request that the carrier review its…”
Nat'l Kidney Patients Ass'n v. Louis W. Sullivan, M.D., 902 F.2d 51 (D.C. Cir. 1990). “§ 1395u(a) (1989); 42 C.F.R. §§ 405.803 , 421.200 (1988). In 1985, HHS amended its regulations to permit carriers to modify “inherently unreasonable” charges.”
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